11/13/2017 non vascular bone grafting for proximal pole ... · •50 scaphoid non union •treated...
TRANSCRIPT
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Non Vascular Bone grafting for Proximal Pole Non Unions
Nader Paksima, DO, MPH
Clinical Professor of Orthopedic Surgery
NYU/Hospital for Joint Diseases
Good Carpentry Is Better than Good Biology !
Risk of osteonecrosis goes up with proximal fractures
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How proximal ?
Blood Supply
• Main blood supply: dorsal branch of the radial artery– Enters through dorsal ridge – ~80% of blood supply– Supplies proximal portion by retrograde blood flow
• Secondary blood supply: Superficial palmar branch of radial artery – 20‐30% of the scaphoids blood supply– Supplies distal portion
• Proximal pole of the scaphoid relies entirely on the intramedullary blood flow
•
Does Osteonecrosis mean it cannot heal?
Does osteonecrosis mean you MUST do a vascularized bone Flap?
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ASSH 2017
Scott Wolfe et al, paper 59 36 scaphoid non‐unions23 evaluated for osteonecrosis ( proximal pole)50% histologic evidence of avascularity91% of these and 94% over all healed. Non vascular bone graft and screw fixation
Is time a factor?
• Chronic Scaphoid Nonunion of 28‐Year Duration Treated with Nonvascularized Iliac Crest Bone Graft
• John T. Capo, MD,1 Ben Shamian, MD,1 and Steve Rivero, BS1
Merrell et al JHS 2002
• Meta‐analysis 2002
• > 1100 articles
• 88% union with vascular grafts
• Better than non vascular
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Chang et al 2006 JHS
• 50 scaphoid non union • Treated with 1,2 ICSRA flap• 34 healed ( 68%)• Difficult fixation, graft extrusion and loss
Proximal pole non‐union Why go non‐vascular?
• Vascular rates of healing not as good as initially reported
• Difficult to do good carpentry
• Can excise small fragments, if its big enough to bone graft , bone graft. If not excise!
• Good carpentry is better than good biology !
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
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Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
From John Capo, MD
21 y.o. male, fell 6 weeks ago
Very small proximal fragment
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Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
95% of cancellous grafts and 92% of cortico‐cancellous grafts heal.
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Dorsal Approach and Bone grafting for Scaphoid Nonunion
Case from Joseph Gower MD
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In Situ HCS with bone graft for scaphoid nonunion
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Case from Joseph Gower MD
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Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
Proximal pole non union 25 Year old
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Proximal pole non union 25 Year old
Inlay graft, Radial Styloidectomy
Inlay bone graft, must Burr out all the dead bone
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Healed
Healed
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Case from Martin Posner MD
Case from Martin Posner MD
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
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Sandow et al 47 patients 2001 Tech Hand Upp Ext SurgVeitch et al 14 patients 2007 JBJS Br
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
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Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
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Options:Redo , with vascular graft
Excise the fragment and take out the screw!
5 year follow up
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Case from Steve Heithoff, DO
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Case from Martin Posner MD
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Maybe we should just….
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Thank You